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F ', �-( Document Name: Document Revised:28Feb2014 <br /> Sample on Upon Receipt Form Page i of 1 <br /> eAnalytical® Document No.: issuing Authority: <br /> F-MN-L-213- 09 Pace Minnesota Q7uality Office <br /> Project Nd w0# • 1 0265■ 6 1 <br /> SMEClient Name: V <br /> Tefm hr 1-\ jlllllllllilllllllllll <br /> Courier. �jFed Ex ❑UPS ❑USPS ❑Client <br /> 10265761 <br /> ❑Commercial 'q��yR'a/c�e � �Z pee0ee� )❑other: <br /> Z«� <br /> Tracking Number: G `r -L [ 0 .� 1� Oly M 1 �j IProj.Due Date; Proj.Namr.. <br /> Custody seal on Cooler/Box Present? []Yes ONO Seats Intact? ❑yes (ZJNo <br /> Optional: <br /> Packing Material: ❑Bubble Wrap oBubble Bags ❑None ❑Other: Temp Blank? Zyes QNO <br /> ❑1188A9130516413 �B88A912167504 Type of Ice: j2fWet ❑Blue ❑None ❑Samples on ice,cooling process has begun <br /> Thermom.Used: qq pp(( Cq. B88A9132521491 <br /> ooler Temp Corrected(°C): �' <br /> <L -7.V Z4{ Z11 5,61 15 Biological Tissue Frozen? ❑Yes No �jN/A <br /> Cooler Temp Read vee ) ! <br /> Temp should be above freezing to 6'C Correction Factor: (/.d Date and Initials of Person Examining Contents: <br /> Comments: <br /> Chain of Custody Present? Yes <br /> Chain of Custody Filled Out? YesNo ❑ 2. <br /> Chain of Custody Relinquished? Yes ❑No 3. <br /> Sampler Name and/or Signature do COC? yes ON. 4. <br /> Samples Arrived within Hold Time? Yes ❑No 5. <br /> Short Hold Time Analysis 42 hr? IE11Y2e::�: <br /> o Rush Tum Around Time Requested? No 7. e <br /> Sufficient Volume? ZYes ❑No 8. � S2 <br /> Correct Containers Used? C,lyes ❑No 9. <br /> -Pace Containers Used? Yes ONO u <br /> Containers Intact? Yes No 10. <br /> Filtered Volume Received for Dissolved Tests? Yes No 11. <br /> UA? Y501�1 <br /> Sample Labels Match COC? { ^T [:]Yes XNo 12. %�)Ptl 0 <br /> -Includes Date/Time/ID/Analysis Matrix- <br /> All <br /> All containers needing acid/base preservation have been ❑yes [:]No /A 13. ❑HNOs []H2SO4 []NaOH ❑HCI <br /> checked? <br /> All containers needing preservation are found to be in r 1 Sample# <br /> compliance with EPA recommendation? ❑Yes ONO NN//A <br /> (HNOs,H,SOCI<2;NaOH>9 Sulfide,NaOH>12 Cyanide) <br /> Exceptions: O Coliform,TOC,Oil and Grease, Yes ONO Initial when , Lot#of added <br /> DRO/8015(water)DOC completed:_ preservative: <br /> Headspace in VOA Vials(>6mm)7 Yes VjNo N/A 14. <br /> Trip Blank Present? ZYes ❑No N/A 15. <br /> Trip Blank Custody Seals Present? f JZYes ❑No N/A <br /> Pace Trip Blank Lot#(if purchased): lq b)� Cam <br /> CLIENT NOTIFICATION/RESOLUTION Field Data Required? Dyes ❑No <br /> Person Contacted: Date/Time: <br /> Comments/Resolution: <br /> Project Manager Review: ° Date: I r wti,{� y rXv' <br /> Note: Whenever there is a discrepancy affe ting North Carolina complia ce samples,a cop this form will be sem tothe North C oliva EHN- R Ce ificatlon Office(i.e out of <br /> hold,incorrect preservative,out of temp,incorrect containers) _ <br /> Page 41 of 41 <br />